<%@ Control Language="c#"  %>
<%@ Register Assembly="Syrinx.Gui.AspNet.Nitobi2" Namespace="Syrinx.Gui.AspNet.Nitobi2" TagPrefix="snc" %><%@ Register Assembly="NitobiControls" Namespace="Nitobi" TagPrefix="ntb" %>
<table border="0" cellspacing="0" cellpadding="0" style="border-collapse: collapse" bordercolor="#111111">
    <tr><td colspan="2" bgcolor="#ECECEC" height="23">Credit Card Information:</td>
	</tr>
		<tr>
			<td colspan="2" bgcolor="#DADADA">
			<img border="0" src="images/clear.gif" width="1" height="1"></td>
		</tr>

		<tr>
			<td colspan="2">Please provide your  credit card informationbelow. <br><font color="#B00000">*</font> Indicates a required field.</td>
		</tr>
		<tr>
			<td colspan="2"><font size="1">&nbsp;&nbsp; </font></td>
		</tr>

		<tr>
			<td>&nbsp;</td>
			<td>
			<img border="0" src="images/ccimages.gif"></td>
		</tr>
		<tr>
			<td colspan="2"><font size="1">&nbsp;&nbsp; </font></td>
		</tr>

		<tr>
			<td align="right">Type of Credit Card:<font color="#B00000">*&nbsp;&nbsp;&nbsp; </font></td>
			<td height="25">
                        	<select size="1" name="ctype" onChange="CVV.src='images/' + theForm.ctype.value + '.gif';">
								<option value="MasterCard">MasterCard</option>
								<option value="Visa">Visa</option>

								<option value="American Express">American Express
                                </option>
								<option value="Discover">Discover</option>
							</select>&nbsp;&nbsp;&nbsp;&nbsp; </td>
		</tr>
		<tr>
			<td align="right">Credit Card Number:<font color="#B00000">*&nbsp;&nbsp;&nbsp; </font></td>

			<td height="25">
			<input TYPE="text" SIZE="12" NAME="cnumber" maxlength="20" style="width:178px;" class="forminput"></td>
		</tr>
		<tr>
			<td align="right">Expiration Date:<font color="#B00000">*&nbsp;&nbsp;&nbsp; </font></td>
			<td height="25">
						<select NAME="cmonth" size="1" class="forminput">

                          <option value="01">01</option>
                          <option value="02">02</option>
                          <option value="03">03</option>
                          <option value="04">04</option>
                          <option value="05">05</option>
                          <option value="06">06</option>

                          <option value="07">07</option>
                          <option value="08">08</option>
                          <option value="09">09</option>
                          <option value="10">10</option>
                          <option value="11">11</option>
                          <option value="12">12</option>

                        </select>&nbsp;
                                                           <select NAME="cyear" size="1" class="forminput">
                                                     <option value="2006">2006</option>
                                                        <option value="2007">2007</option>
                                                        <option value="2008">2008</option>
                                                        <option value="2009">2009</option>
                                                        <option value="2010">2010</option>

                                                        <option value="2011">2011</option>
                                                        <option value="2012">2012</option>
                                                        <option value="2013">2013</option>
                                                        <option value="2014">2014</option>
                                                        <option value="2015">2015</option>
                                                        <option value="2016">2016</option>

                                                        <option value="2017">2017</option>
                                                        <option value="2018">2018</option>
                                                        <option value="2019">2019</option>
                                                        <option value="2020">2020</option>
                                                        <option value="2021">2021</option>
                                                        <option value="2022">2022</option>

                                                        <option value="2023">2023</option>
                                                </select></td>
		</tr>
		<tr>
			<td valign="top" align="right">Card Verification #<font color="#B00000">*&nbsp;&nbsp;&nbsp; </font></td>
			<td height="23" valign="top">
			<table border="0" width="100%" cellspacing="0" cellpadding="0">

				<tr>
					<td valign="top"><input type="text" name="cvv" size="5" maxlength="4" class="forminput"></td>
					<td valign="top">
					<img border="0" name = "CVV" src="images/mastercard.gif" width="215" height="103"></td>
				</tr>
			</table>
